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SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> AUG 0 5 2011 ENVIRONMENTAL HEALTH DEPAR� <br /> 1868 East Hazelton Avenue, Stockton, CA 95 0 6232 <br /> CIeIVIROFIMENTALHER*^ Telephone: (209)468-3420 Fax: (209)464-0138 Web www.sjgov.org/ehd <br /> or:ghrf TISERV10E8 PUBLIC RECORDS RELEASE APPLICATION f <br /> PPLICANT: )( a�ra_ BUSI14ESS/AGENCY: <br /> ADDRESS: LO vl r lii'ei ckR'-C CITY/STATE/Z(P: <br /> PHONE (1): PHONE(2): FAX OR E-MAIL: �hco!'clic <br /> Please allow 10 business days from date Of application submittal for the records to be available. <br /> Staff will contact you to arran a an appointment date and time to review the requested records. <br /> CHECK BOX TO EXPEDITE REQ EST-$139 FE H OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAPS <br /> SIGNATURE OF APPLICANT_ I <br /> 1. List un to ten addresses in the s ace below. $elect the DATE (F 1.5—" /- <br /> p type(s) of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address indicated above Address <br /> ranges will not be accepted.Applications received after 3:00 pm will be processed the next business day. <br /> 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted above. <br /> 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br /> days after receipt of application. The files will be held for a maximum of five business days for review. Appointment=_ <br /> should be scheduled accordingly. <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$1339 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 6:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List ❑ Map— Description: <br /> Specific Date Range of Information Requested: From E-CUto (4 � — <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FLE ADDRESS <br /> FILES EHD USE ONLY <br /> UNDERGROUND TANK(UST) Street# Street Name City <br /> CLEANUP SITE(LOP) I ��.L t1( S E(yL I Srt_ <br /> h COrvSUMER <br /> Etil"LI .Cu ❑ <br /> )'OTHER CLEANUP SITE(NON-LOP) 1 <br /> 1].4 HAZARDOUS WASTE n I I1"14I'l L` m I r. <br /> O TIERED PERMITTED FACILITY 2 ❑DAIRY <br /> ��OVEGROUND TANK 3 W. Ave,nM, A r1, <br /> R UST (MONITORING/REMOVAL) ❑PWS <br /> ,HAZARDOUS MATERIALS 3 <br /> �.SPIWRELEASE RESPONSE <br /> ❑SOLID WASTE FACILITY/VEHICLE _ 4 WATER OUALPY <br /> ❑FOOD FACILTI <br /> ❑POOL/SPA Srt MmSATION <br /> ❑DAIRY 6 <br /> ❑LAND USE APPLICATION SITES <br /> ❑SEPTIC PUMPER TRUCK/ 6 ❑HOUSING <br /> YARD/CHEMICAL TOILETS <br /> ❑WASTEWATER TREATMENT PLANT COPA <br /> ❑HOUSING ABATEMENT 7 <br /> ❑MOTEUHOTEL <br /> ❑CHICKEN RANCH/DOG KENNEL CUPA-UST <br /> F1 MEDICAL WASTE FACILITY 8 <br /> ❑TATTOO/BODY PIERCING <br /> ❑WASTE TIRE B ❑SOLID WASTE <br /> ❑COMPLAINT <br /> gOTHER(PLEASE SPECIFY): ❑ACCOUNTING <br /> v <br /> "'BOXED AREA-EHD USE ONLY"' <br /> Imo' <br /> I <br /> I <br /> ❑ Records provided by Staff-PPR Complete. staff Name: - <br /> EHD 48-06 <br />